Free Microsoft Word - CSD601 - Minnesota

State of Minnesota County

District Court Judicial District: Court File Number: Case Type:



In Re the Marriage of:

Plaintiff / Petitioner vs / and Defendant / Respondent Intervenor

Notice to Obligor of Medical Support Enforcement

TO:

, Obligor You are hereby notified pursuant to Minnesota Statute 518A.41, that thirty (30) days

have passed since entry of the court order dated that application for insurability has been made.

.

You have

failed to provide written proof that the required health and dental insurance has been obtained, or If, after fifteen (15) days from the date of this notice, written proof that the insurance coverage exists is not received at the address listed below, a copy of the court order for insurance coverage will be forwarded to your employer or union. This order is binding on your employer or union. Upon receipt of the order, your employer or union will enroll the minor child(ren) named in the order as beneficiaries in an insurance plan and withhold any required premium from your income or wages. If more than one plan is offered by your employer or union, the child(ren) will be enrolled in the least costly plan otherwise available to you that is comparable to a number two qualified plan as defined by Minnesota Statute 62E.06, subdivision 2 (2006). The child(ren) will remain eligible for insurance coverage until emancipated or until further order of the court.

CSD601

ENG

State

04/08

www.mncourts.gov/forms

Page 1 of 2

If dependent health and dental insurance is available for the benefit of your (ex-) spouse at no additional cost, the employer or union will also enroll that person. If you fail to maintain the health care coverage as ordered, you will be liable to the obligee for any medical or dental expenses incurred from the date of the court order. Proof of failure to maintain insurance constitutes a showing of increased need by the obligee pursuant to Minnesota Statute 518A.39 and provides a basis for a modification of your child support order.

Dated:
Signature Print Name: Address: City/State/Zip: Telephone: ( Attorney for: )

CSD601

ENG

State

04/08

www.mncourts.gov/forms

Page 2 of 2